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Background: Severe hypertriglyceridemia is often caused by variants in genes of triglyceride metabolism. These variants include rare, heterozygous pathogenic variants (PVs), or multiple common, small-effect single nucleotide polymorphisms that can be quantified using a polygenic risk score (PRS). The role of genetic testing to examine PVs and PRS in predicting risk for pancreatitis and severity of hypertriglyceridemia is unknown. Methods: We examined the relationship of PVs and PRSs associated with hypertriglyceridemia with the highest recorded plasma triglyceride level and risk for acute pancreatitis in 363 patients from 3 academic lipid clinics who underwent genetic testing (GBinsight’s Dyslipidemia Comprehensive Panel). Categories of hypertriglyceridemia included: normal triglyceride ( Results: PVs and high PRSs were identified in 37 (10%) and 59 (16%) individuals, respectively. Patients with both had increased risk for very severe hypertriglyceridemia compared with those with neither genetic risk factor. Risk for acute pancreatitis was also increased in individuals with both genetic risk factors (odds ratio, 5.1 [ P =0.02] after controlling for age, race, sex, body mass index, and highest triglyceride level), but not in individuals with PV or high PRS alone. Conclusions: The presence of both PV and high PRS significantly increased risk for very severe hypertriglyceridemia and acute pancreatitis, whereas PV or PRS alone only modestly increased risk. Genetic testing may help identify patients with hypertriglyceridemia who have the greatest risk for developing pancreatitis and may derive the greatest benefit from novel triglyceride-lowering therapies.

Background: Non-contrast chest CTs (NCCT) are performed routinely for coronary artery calcium (CAC) scoring and lung cancer screening. However, a large amount of noncoronary and nonpulmonary data from these scans remain unassessed. We aimed to validate a deep learning model to automatically segment and measure left atrial (LA) volumes from routine NCCT and evaluate prediction for cardiovascular outcomes. Methods: We retrospectively evaluated 273 patients (median age 69 years, 55.5% male) who underwent a routine non-ECG gated NCCT for lung cancer screening. LA volumes were quantified by three expert cardiothoracic radiologists and a prototype AI algorithm. LA volumes were then indexed to the body surface area (BSA). Expert and AI LA volume index (LAVi) were compared and used to predict cardiovascular outcomes within five years. Logistic regression with appropriate univariate statistics were used for modelling outcomes. Findings: There was excellent correlation between AI and expert results with an LAV intraclass correlation of 0.950 (0.936-0.960). Bland-Altman plot demonstrated the AI underestimated LAVi by a mean 5.86 mL/m 2 . AI-LAVi was associated with new-onset atrial fibrillation (AUC 0.86; OR 1.12, 95% CI 1.08-1.18, p

To evaluate the effectiveness of a novel artificial intelligence (AI) algorithm for fully automated measurement of left atrial (LA) volumes and function using cardiac CT in patients with atrial fibrillation.We included 79 patients (mean age 63 ± 12 years; 35 with atrial fibrillation (AF) and 44 controls) between 2017 and 2020 in this retrospective study. Images were analyzed by a trained AI algorithm and an expert radiologist. Left atrial volumes were obtained at cardiac end-systole, end-diastole, and pre-atrial contraction, which were then used to obtain LA function indices. Intraclass correlation coefficient (ICC) analysis of the LA volumes and function parameters was performed and receiver operating characteristic (ROC) curve analysis was used to compare the ability to detect AF patients.The AI was significantly faster than manual measurement of LA volumes (4 s vs 10.8 min, respectively). Agreement between the manual and automated methods was good to excellent overall, and there was stronger agreement in AF patients (all ICCs ≥ 0.877; p0.001) than controls (all ICCs ≥ 0.799; p0.001). The AI comparably estimated LA volumes in AF patients (all within 1.3 mL of the manual measurement), but overestimated volumes by clinically negligible amounts in controls (all by ≤ 4.2 mL). The AI's ability to distinguish AF patients from controls using the LA volume index was similar to the expert's (AUC 0.81 vs 0.82, respectively; p = 0.62).The novel AI algorithm efficiently performed fully automated multiphasic CT-based quantification of left atrial volume and function with similar accuracy as compared to manual quantification. Novel CT-based AI algorithm efficiently quantifies left atrial volumes and function with similar accuracy as manual quantification in controls and atrial fibrillation patients.• There was good-to-excellent agreement between manual and automated methods for left atrial volume quantification. • The AI comparably estimated LA volumes in AF patients, but overestimated volumes by clinically negligible amounts in controls. • The AI's ability to distinguish AF patients from controls was similar to the manual methods.

Bempedoic acid is an adenosine triphosphate-citrate lyase (ACL) inhibitor that reduces levels of low-density lipoprotein-cholesterol (LDL-C) in the plasma by inhibition of cholesterol synthesis in hepatic cells, which leads to up-regulation of hepatic LDL receptors. Bempedoic acid is approved as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) who require additional lowering of LDL-C. In this case study, we describe a patient with HeFH who had a prior excellent response to statin but unable to take the same, and a less than expected response to PCSK9i, in whom initiation of bempedoic acid led to a substantial reduction of LDL-C. Our findings suggest that patients who are quite responsive to statins may also be quite responsive to bempedoic acid, a medication that works in the same biochemical pathway as HMG-CoA reductase inhibitors. Additionally, this medication may be particularly effective at lowering LDL-C among individuals not on background statin therapy.

Introduction: This study was performed to evaluate a novel AI algorithm for fully automated measurement of LA volumes and function using cardiac CTA in patients with atrial fibrillation (AF). Methods: A prototype AI algorithm (AI-LAV), with a conditional variational auto-encoder architecture, was developed and trained using 555 manually annotated ECG-gated, contrast-enhanced cardiac CTs. A total of 79 patients (mean age 63 ± 12 years; 35 with AF and 44 controls) evaluated between 2017 and 2020 were included in this retrospective study to validate the AI model. Images were analyzed by the trained AI algorithm and experienced radiologists. Left atrial volumes were obtained at cardiac end-systole (LAVmax), end-diastole (LAVmin), and pre-atrial contraction (LAVpc), which were then used to obtain LA function indices (total, passive, and active emptying fractions). Statistical analysis was performed. Results: AI was significantly faster than manual measurement of LA volumes and function (4 s vs 10.8 min, respectively). Agreement between the manual and automated methods was good to excellent overall, and there was stronger agreement in AF patients (all ICCs ≥ 0.877; p Conclusion: In a validation cohort, the novel AI algorithm efficiently performed fully automated multiphasic CTA-based quantification of left atrial volume and function with similar accuracy to expert manual quantification. Figure. Scatter and Bland-Altman plots for LAVmax and LAVmin. Segmentation comparison between expert (manual) and AI on cardiac CTA.

There is little consensus on whether absence of coronary artery calcium (CAC) can identify patients with chest pain (CP) who can safely avoid additional downstream testing.The purpose of this study was to conduct a systematic review and meta-analysis investigating the utility of CAC assessment for ruling out obstructive coronary artery disease (CAD) among patients with stable and acute CP, at low-to-intermediate risk of obstructive CAD undergoing coronary computed tomography angiography (CTA).The authors searched online databases for studies published between 2005 and 2021 examining the relationship between CAC and obstructive CAD (≥50% coronary luminal narrowing) on coronary CTA among patients with stable and acute CP.In this review, the authors included 19 papers comprising 79,903 patients with stable CP and 13 papers including 12,376 patients with acute CP undergoing simultaneous CAC and coronary CTA assessment. Overall, 45% (95% CI: 40%-50%) of patients with stable CP and 58% (95% CI: 50%-66%) of patients with acute CP had CAC = 0. The negative predictive values for CAC = 0 ruling out obstructive CAD were 97% (95% CI: 96%-98%) and 98% (95% CI: 96%-99%) among patients with stable and acute CP, respectively. Additionally, the prevalence of nonobstructive CAD among those with CAC = 0 was 13% (95% CI: 10%-16%) among those with stable CP and 9% (95% CI: 5%-13%) among those with acute CP. A CAC score of zero predicted a low incidence of major adverse cardiac events among patients with stable CP (0.5% annual event rate) and acute CP (0.8% overall event rate).Among over 92,000 patients with stable or acute CP, the absence of CAC was associated with a very low prevalence of obstructive CAD, a low prevalence of nonobstructive CAD, and a low annualized risk of major adverse cardiac events. These findings support the role of CAC = 0 in a value-based health care delivery model as a "gatekeeper" for more advanced imaging among patients presenting with CP.

Introduction Transcatheter aortic valve replacement (TAVR) has become a widely accepted treatment option for patients with severe aortic stenosis (AS) who are considered intermediate- and high-risk surgical candidates. The purpose of this study was to test the hypothesis that trans-apical TAVR would be associated with increased risk of new-onset intraventricular conduction delay (LBBB or RBBB). Methods We conducted a retrospective observational study of consecutive patients undergoing TAVR at a large, single institution. The incidence of new LBBB or RBBB was compared between femoral and apical TAVR patients. Multivariate analysis was performed to account for confounding variables, which included age, gender, CAD, PAD, hypertension, and diabetes. Results A total of 467 TAVR patients were included in the study, with 283 (60.6%) femoral approach and 184 (39.4%) apical approach. In univariate analysis, the apical approach (when compared to the femoral approach) was associated with a higher incidence of both new-onset LBBB (12.79 vs. 3.40%, p = 0.0002) and RBBB (5.49 vs. 0.81%, p = 0.0039). After controlling for potential confounding variables, the apical approach continued to be associated with a higher incidence of both new-onset LBBB (p = 0.0010) and RBBB (p = 0.0115). There was also a trend towards an association between diabetes and new-onset LBBB (p = 0.0513) in apical TAVR patients. In subgroup analysis, LBBB/RBBB occurring as a result of transapical TAVR was associated with more frequent hospitalizations > 30 days after TAVR, compared to transfemoral TAVR. Other post-procedural complications noted more frequently among patients undergoing transapical TAVR include arrhythmias including atrial fibrillation, peri-procedural myocardial infarction (within 72 h), mortality from unknown cause, and mortality from non-cardiac cause. Conclusions Relative to transfemoral TAVR, patients undergoing transapical TAVR are at increased risk for new-onset bundle branch block, peri-procedural myocardial infarction, rehospitalization, TAV-in-TAV deployment, and all-cause mortality at 1 year. Interventional cardiologists and cardiothoracic surgeons alike should take these findings into consideration when choosing which approach is most suitable for patients undergoing TAVR for severe aortic stenosis.

PURPOSE OF REVIEW: The potential of polygenic risk scores (PRS) to improve atherosclerotic cardiovascular disease (ASCVD) risk assessment and management has stoked significant interest in their incorporation into clinical management. The goal of this review is to apprise the reader of the latest developments and evidence of PRS readiness for clinical integration. We also discuss current limitations that must be addressed before PRS can be implemented into routine clinical practice. RECENT FINDINGS: PRS have been shown to improve risk stratification for ASCVD and to identify patients who may derive increased benefit from primary and secondary prevention. Risk captured by PRS appears largely independent of traditional risk factors and can be ascertained at birth, prior to the development of traditional clinical risk factors. Genetic risk is modifiable through lifestyle modifications and medications. SUMMARY: PRS offers a valuable way to improve early identification of actionable CVD risk. However, further work is needed before PRS can be implemented clinically.

Given rapid advancements in medical science, it is often challenging for the busy clinician to remain up-to-date on the fundamental and multifaceted aspects of preventive cardiology and maintain awareness of the latest guidelines applicable to cardiovascular disease (CVD) risk factors. The “American Society for Preventive Cardiology (ASPC) Top Ten CVD Risk Factors 2021 Update” is a summary document (updated yearly) regarding CVD risk factors. This “ASPC Top Ten CVD Risk Factors 2021 Update” summary document reflects the perspective of the section authors regarding ten things to know about ten sentinel CVD risk factors. It also includes quick access to sentinel references (applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis/smoking, kidney dysfunction and genetics/familial hypercholesterolemia. For the individual patient, other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the “ASPC Top Ten CVD Risk Factors 2021 Update” to provide a succinct overview of things to know about ten common CVD risk factors applicable to preventive cardiology.

Purpose The current literature reports a wide range of diagnostic accuracy of non-contrast magnetic resonance coronary angiography (NC-MRCA) for the assessment of coronary artery disease (CAD). We aimed to compare the clinical effectiveness of NC-MRCA with that of invasive coronary angiography (ICA) in patients with suspected CAD using a systematic review and meta-analysis. Methods Two investigators independently extracted 36 published manuscripts between 2010 and 2019. Databases including Medline, Web of Knowledge, Google Scholar, Scopus, and Cochrane were searched using pre-established keywords. Analysis of the data followed the PRISMA statement for reporting systematic reviews and meta-analyses and primary analysis followed the Mantel-Hansel methodology. Correctness of classification for detecting coronary artery stenosis ≥50% (CAS) was measured using ICA as the gold standard. Results A total of five studies met inclusion criteria, with a total of 417 patients and 2883 coronary segments. The pooled per patient sensitivity and specificity of NC-MRCA for CAS in suspected patients was 90.3% (95% CI 85.6–95.1%) and 77.9% (95% CI 69.5–86.3%). Pooled per vessel assessment of NC- MRCA revealed a sensitivity of 83.7% (95%CI 79.7–87.8%) and specificity of 90.0% (95%CI 86.7–93.4%). Per-segment assessment of NC-MRCA showed a pooled sensitivity of 81.6% (95% CI 76.8–86.4) and specificity of 97.0% (95% CI 95.5–98.5). Mild to moderate heterogeneity was noted in most diagnostic parameters with larger heterogeneity noted in the per-segment analyses. There was less heterogeneity in sensitivity and NPV than specificity and PPV. Conclusion According to this meta-analysis, non-contrast coronary MRA resulted in adequate screening in patients with suspected CAD with high sensitivity and specificity. This result was true for per-patient, per-vessel, and per-segment assessment., non-contrast magnetic resonance angiography, coronary angiography, coronary artery disease, accuracy

Purpose Cardiovascular disease (CVD) is the leading cause of death in adults in the United States, yet the benefits of genetic testing are not universally accepted. Methods We developed the "HeartCare" panel of genes associated with CVD, evaluating high-penetrance Mendelian conditions, coronary artery disease (CAD) polygenic risk, LPA gene polymorphisms, and specific pharmacogenetic (PGx) variants. We enrolled 709 individuals from cardiology clinics at Baylor College of Medicine, and samples were analyzed in a CAP/CLIA-certified laboratory. Results were returned to the ordering physician and uploaded to the electronic medical record. Results Notably, 32% of patients had a genetic finding with clinical management implications, even after excluding PGx results, including 9% who were molecularly diagnosed with a Mendelian condition. Among surveyed physicians, 84% reported medical management changes based on these results, including specialist referrals, cardiac tests, and medication changes. LPA polymorphisms and high polygenic risk of CAD were found in 20% and 9% of patients, respectively, leading to diet, lifestyle, and other changes. Warfarin and simvastatin pharmacogenetic variants were present in roughly half of the cohort. Conclusion Our results support the use of genetic information in routine cardiovascular health management and provide a roadmap for accompanying research.

Purpose of review The purpose of this review is to compare and contrast the key messages from the 2018 American Heart Association (AHA)/American College of Cardiology (ACC) Multisociety Guideline on the Management of Blood Cholesterol and the 2019 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) Guidelines for the Management of Dyslipidemias. We also review some of the evidence that served as the basis for these guidelines and share our opinion regarding these guidelines. Recent findings Patients with atherosclerotic cardiovascular disease (ASCVD), severe hypercholesterolemia, familial hypercholesterolemia, or diabetes should be treated aggressively with lipid-lowering therapy. In addition to traditional risk factors included in risk scores, assessment of risk enhancers/modifiers may improve risk stratification. The addition of ezetimibe ± proprotein convertase subtilisin/kexin type 9 inhibitors plays an integral role in the management of very-high-risk ASCVD patients; the ESC/EAS guidelines support more aggressive use of these medications. Summary Both the AHA/ACC Multisociety and ESC/EAS guidelines provide an evidence-based approach to management of blood cholesterol. The greatest difference between these two guidelines is the classification and recommended management of very-high-risk patients. Implementation of either guideline will likely lead to improved ASCVD outcomes compared with current treatment practice. Video abstract http://links.lww.com/COE/A22.

Introduction: Coronary computed tomography angiography (CCTA) is a class IIA recommendation in low-intermediate risk patients with suspected acute coronary syndrome (ACS) and a normal or nondiagnostic cardiac biomarker and ECG. However, there is little consensus on whether absence of coronary artery calcium (CAC) can safely identify patients with stable and acute chest pain (CP) who can avoid more advanced downstream testing. In this study, we conducted a systematic analysis investigating utility of CAC zero in ruling out obstructive coronary artery disease (CAD) among patients with stable and acute CP undergoing coronary CT angiography (CCTA). Methods: We searched online databases (PubMed, MEDLINE) for original research articles published between 2005 and 2020 examining the relationship between CAC and significant stenosis on CCTA (defined as >50% coronary luminal narrowing) among patients with stable and acute chest pain. Results: A systematic review of published articles revealed 18 studies including 27,719 patients with stable CP and 12 studies including 7,184 patients with acute CP undergoing simultaneous CCTA and CAC scoring. Overall, 12,664 (45%, 95% CI: 39%-50%) patients with stable CP and 4,327 (56%, 95% CI: 48%-64%) patients with acute CP had CAC zero. The pooled prevalence of obstructive CAD among those with CAC=0 was 3% (95% CI: 2%-4%) among stable CP patients and 2% (95% CI: 1%-3%) among acute CP patients. The negative predictive values for any CAC ruling out obstructive disease were 97% (95% CI: 96-98%) and 98% (95% CI: 96-100%), respectively (Figure). Conclusions: Among over 34,000 patients with stable and acute CP patients undergoing CCTA, the absence of CAC was associated with a very low likelihood of obstructive CAD. These findings support role of CAC zero in a value-based healthcare delivery model as a gatekeeper for more advanced testing.

Introduction: Cardiovascular disease prevention entails treatment of multiple risk factors, including diabetes (DM), hypertension (HTN), and hyperlipidemia (HLD), based on guidelines that promote the use of combination therapy when monotherapy does not achieve treatment goals. The purpose of this study is to determine how frequently combination pharmacotherapy is employed to manage these disorders among patients with atherosclerotic cardiovascular disease (ASCVD), based on the GOULD registry. Methods: The multicenter, observational GOULD registry describes low-density lipoprotein cholesterol (LDL-C) treatment patterns over time in adults with clinical ASCVD in the United States. Patients were enrolled into 3 cohorts: 1) Currently on PCSK9 inhibitor (PCSK9i), or not on PCSK9i with 2) LDL-C 70-99 mg/dL, or 3) LDL-C ≥100 mg/dL. We determined the prevalence of DM and HTN within this registry, the classes of medications used to treat these disorders, and how frequently patients were on two or more medications to treat these disorders at baseline, 6, 12, 18, and 24 months, respectively. Results: Among 5,006 patients in this cohort on lipid-lowering therapy (LLT), 35.2% had DM and 86.0% had HTN at baseline. Of those receiving treatment, 47.6% and 71% were receiving two or more medications for management of DM and HTN, respectively. In contrast, only 19.5% of patients were receiving two or more LLT medications (51.9% among PCSK9i subjects, 15.4% among LDL-C subjects) (Figure). There was a modest increase in combination lipid therapy from 19.5% at baseline to 25.6% at 24 months. Conclusions: Despite recent guidelines supporting the use of combination therapy in patients with high risk ASCVD with an LDL-C above threshold after statin therapy, this high-risk group continues to be managed mostly with statin monotherapy in contrast to the widespread use of combination therapy for the treatment of DM and HTN.

PURPOSE We evaluated the prevalence of coronary stenosis on coronary computed tomography angiography (CCTA) in patients aged 18 to 30 years, who presented to the emergency department with chest pain. We also examined the risk factors potentially associated with abnormal coronary findings on CCTA in this age group. MATERIALS AND METHODS A total of 884 patients were retrospectively evaluated. Indication for CCTA was guided by our hospital's chest pain protocol based on ACC/AHA guidelines. These were performed using the standard technique and interpreted based on CAD-RADS guidelines. Scans were identified as abnormal if atherosclerotic coronary artery disease (CAD), myocardial bridging (MB), or any anatomic coronary artery anomaly were present. RESULTS Twenty-two percent of patients had a coronary abnormality on CCTA. The most common abnormality was MB (17.3%), followed by CAD (4.4%) and coronary anomalies (1.5%). A small minority had stenosis (2.8%), most commonly caused by CAD. Most cases with stenosis were minimal to mild (72%) with 0.8% having coronary stenosis ≥50%. Age and male sex were risk factors for both coronary artery stenosis (odds ratio: 1.32 and 4.50, 95% confidence interval: 1.03-1.69, and 1.23-16.46, P=0.028 and 0.023, respectively) and CAD (odds ratio: 1.52 and 3.67, 95% confidence interval: 1.14-2.04, and 1.26-10.66, P=0.005 and 0.017, respectively). CONCLUSIONS Epicardial coronary stenosis is rarely the cause of chest pain among young adult patients presenting to the emergency department. Age and male sex were both risk factors for coronary artery stenosis/disease in this age group.

Objectives: To evaluate the role of platelet count and thromboelastogram (TEG) in the treatment of thrombocytopenic cancer patients with suspected coronary artery disease (CAD).Background: Cancer patients with CAD and thrombocytopenia are often treated non-invasively (i.e., without coronary angiography when clinically indicated) due to perceived high risk of bleeding. We sought to evaluate coagulability based on TEG and determine if platelet count and TEG could predict bleeding risk/mortality among cancer patients undergoing coronary angiography (CA).Methods: Baseline demographics, platelet count, and TEG parameters were recorded among cancer patients that underwent CA and had a concomitant TEG. Logistic regression and univariate proportional hazards regression analysis were performed to determine the impact of platelet count and coagulability on 24-month overall survival (OS).Results: All patients with platelet count 50,000/mm3 groups, as well as the improved survival, suggest that with appropriate clinical indication and risk/benefit assessment, a cut-off of 50,000/mm3 platelets can be considered for CA in cancer patients.

Congenital anomalies of superior (SVC) and inferior vena cava (IVC) are not uncommon and usually incidentally recognized. The normal embryogenesis is a complex process involving the formation of several anastomoses. Failure of certain vessels to develop or regress results in numerous caval variations and anomalies. Although these are usually without significant clinical implications, awareness of these anomalies is necessary to avoid diagnostic pitfalls and suggest the presence of other abnormalities and for the planning of vascular intervention or surgery. We present a very rare, caval anomaly, a left-sided IVC with hemiazygos continuation to left SVC in the absence of right SVC.

Little is known about the prevalence and risk factors for coronary artery disease (CAD) in young adults, possibly owing to the limited number of anatomic studies in this patient population. The Partners YOUNG MI Registry demonstrated that myocardial infarction rates among young adults have not

Study design Retrospective consecutive cohort series. Objective The aim of this study was to develop a low-dose computed tomography (CT) protocol for use in robot-assisted pediatric spinal surgery. Summary of background data CT scans are utilized preoperatively for preoperative planning, by navigation software during robot-assisted surgery, and postoperatively to assess surgical implant placement. Traditionally high radiation doses produced by CT scanning are a concern in the highly radiosensitive pediatric population. Methods We developed a low-dose protocol using phantom scans. A cohort of patients undergoing CT scanning using the low-dose protocol was collected. Further, a matching cohort of patients who underwent standard scanning was collected. Image quality was assessed by observer ratings. Radiation doses and image quality metrics were compared for the standard and low-dose protocol patients. Results Effective dose significantly decreased 84% to 91% depending on patient size and whether the scan was preoperative or postoperative. All scans were compatible with the navigation software. No clinically significant differences in image quality were observed between low-dose and standard patient cohorts. Conclusions Task-based CT protocol optimization can produce acceptable image quality with dose comparable to standard two-view radiography. Level of evidence 2.

Carcinoid heart disease is a rare disorder that is associated with significant morbidity and mortality. In this review of the literature, we will present current concepts in diagnosis and management of carcinoid heart disease. Recent expert consensus guidelines highlight the role of echocardiography and screening with NT-proBNP for the evaluation of carcinoid heart disease. Advances in medical therapy along with better surgical outcomes highlight the experience and expertise that has been gained in the treatment of carcinoid heart disease. Carcinoid heart disease occurs in patients with neuroendocrine tumors who have carcinoid syndrome. Serotonin appears to play a central role in the development of carcinoid heart disease. Cardiac biomarkers and multimodality imaging can be used to aid in screening and diagnosis. The mainstay of treatment of carcinoid heart disease is surgery.

Background Pericardial effusion is a known complication in cancer patients, resulting in chest pain, cardiac tamponade, and cardiogenic shock. Although technological advances allow for early detection, treatment options are limited for those also suffering from thrombocytopenia. Purpose Our study aims to evaluate survivorship of thrombocytopenic cancer patients who underwent pericardiocentesis. Methods From 2008 to 2019, we assessed overall mortality and follow-up post-pericardiocentesis in cancer patients with concurrent thrombocytopenia ( Results In 137 patients, we identified 65 (47%) patients with Grade 1, 30 (22%) with Grade 2, and 42 (31%) with Grade 3 thrombocytopenia. The calculated platelet count average was 66x103 cells/mL, median was 59x103 cells/mL, and range was 6 to 147x103 cells/mL. Of note, 7 (5%) patients had platelets Conclusion Pericardiocentesis offers rapid symptomatic relief and can be life-saving in cardiac tamponade. In cancer patients, the development of pericardial effusions and thrombocytopenia increases due to the underlying malignancy and cancer therapeutics. Although thrombocytopenia is thought to increase peri-procedural risks, in this cohort there was only one minor complication and this occurred in Grade 2 thrombocytopenia. For thrombocytopenic cancer patients suffering from large pericardial effusions, high pre-operative risk scores often exclude them from receiving surgical pericardial windows. Although mortality was higher in severe thrombocytopenia, this is likely due to the competing risk of more severe cancer; there were no complications with Grade 1 thrombocytopenia. Especially noteworthy, no complications in those with platelets

Anomalous coronary vasculature is a rare finding among the general population. Identifying such cases is important for preventing adverse outcomes such as sudden cardiac death. We present two rare cases of aberrant coronary anatomy. In Case 1, a 4-year-old male who presented with non-exertional chest pain was found to have anomalous coronary architecture on echocardiogram. Coronary computed tomography angiogram (CCTA) confirmed an anomalous origin of the left coronary artery from the right coronary sinus with a malignant interarterial course and myocardial bridging of the left anterior descending (LAD) artery. The patient underwent a successful surgical correction of the defects. In Case 2, a full-term infant female was born with a hypoplastic right ventricle and pulmonary atresia. CCTA showed a large fistula originating from the coronary sinus on the left that drained into the superior aspect of the mid right ventricular cavity, an anomalous bridge between the left and right atrial appendages, and five fistulous connections between various vessels. The patient was transferred to another facility for cardiac transplant.

Novel cancer therapies such as checkpoint inhibitors have improved the life expectancy of many cancer patients. However, they have also been associated with the development of myocarditis and (in rare cases) new onset heart failure. The purpose of this study was to determine if checkpoint inhibitor

Background Marijuana is the most popular drug of abuse in the United States. The association between its use and coronary artery disease has not yet been fully elucidated. This study aims to determine the frequency of coronary artery disease among young to middle aged adults presenting with chest pain who currently use marijuana as compared to nonusers. Methods In this retrospective study, 1,420 patients with chest pain or angina equivalent were studied. Only men between 18 and 40 years and women between 18 and 50 years of age without history of cardiac disease were included. All patients were queried about current or prior cannabis use and underwent coronary CT angiography. Each coronary artery on coronary CT angiography was assessed based on the CAD-RADS reporting system. Results A total of 146 (10.3%) out of 1,420 patients with chest pain were identified as marijuana users. Only 6.8% of the 146 marijuana users had evidence of coronary artery disease on coronary CT angiography. In comparison, the rate was 15.0% among the 1,274 marijuana nonusers (p = 0.008). After accounting for other cardiac risk factors in a multivariate analysis, the negative association between marijuana use and coronary artery disease on coronary CT angiography diminished (p = 0.12, 95% CI 0.299-1.15). A majority of marijuana users were younger than nonusers and had a lower frequency of hypertension and diabetes than nonusers. There was no statistical difference in lipid panel values between the two groups. Only 2 out of 10 marijuana users with coronary artery disease on coronary CT angiography had hemodynamically significant stenosis. Conclusion Among younger patients being evaluated for chest pain, self-reported cannabis use conferred no additional risk of coronary artery disease as detected on coronary CT angiography.

Prenatal ultrasonography in the early third trimester showed an unusual branching pattern of the right aortic arch. Echocardiography performed 4 h after birth showed the right aortic arch with mirror-image branching, patent ductus arteriosus, and patent foramen ovale. Because the location of the ductus arteriosus was unclear on echocardiography, cardiovascular magnetic resonance imaging was performed 3 days after birth. Advanced techniques including contrast-enhanced time-resolved magnetic resonance angiography and 3D time-of-flight magnetic resonance angiography allowed accurate diagnosis of a vascular ring comprising ascending and descending aorta, right aortic arch with mirror-image branching, and diverticulum of Kommerell giving rise to a left ligamentum arteriosum. The infant had hiccups, but no other symptoms. The esophagram was negative for obstruction. The infant was closely monitored; however, she developed esophageal obstruction at 7 months of age because of the vascular ring. She underwent lysis of the left ligamentum arteriosum followed by aortopexy for relief of esophageal obstruction. This report shows the utility of neonatal cardiovascular magnetic resonance imaging to evaluate complex congenital aortic arch anomalies.

Our purpose is to discuss the importance of multimodality imaging in the assessment of cardiac tumors and management. We have compiled a recent review of the scientific literature and embedded our clinical pathways and recommendations based on data and clinical experience. The use of contrast echocardiography in the assessment of cardiac masses has been shown to be helpful in distinguishing tumor from thrombus. Deformation imaging of cardiac tumors has been shown to differentiate better rhabdomyomas from fibromas in pediatric patients. Cardiac MRI (CMR) appears to be helpful in determining whether cardiac tumors are benign or malignant by identifying presence of infiltration, uptake of contrast in first pass perfusion and gadolinium enhancement. Patients with evidence of cardiac metastases by CMR show similar survival to stage IV cancer without cardiac metastases. In our institution, we use a standardized approach for the evaluation of cardiac masses, which includes multimodality imaging in the appropriate clinical context. The autotransplantation surgical technique has shown some promise in improving survival in patients with primary cardiac sarcomas. In our institution, we do not routinely recommend anticoagulation for “tumor-thrombus” in renal cell carcinoma due to risk of bleeding from primary tumor. Cardiac masses are often found incidentally, but sometimes can present with cardiovascular symptoms due to obstruction and valvular dysfunction, which may prompt imaging. It is important to determine whether the mass is a normal variant, imaging artifact, vegetation, thrombus, or tumor. Transthoracic echocardiography is ideally suited to be the initial imaging modality because of the portability, wide availability, lack of radiation, and relatively low cost. The gold standard cardiac imaging technique to distinguish tumor from thrombus is contrast enhanced CMR with prolonged inversion time. Advantages of CMR when compared to echocardiography regarding characterization of cardiac tumors are as follows: larger field of view, better spatial resolution, better tissue characterization, lack of attenuation, and ability to image at any prescribed plane. Primary and secondary cardiac tumors have particular characteristics in echocardiography and CMR. Imaging of cardiac tumors plays an important role in establishing a diagnosis and in planning management.

Innovations and discoveries in cancer therapeutics have improved survival rates in patients with various types of malignancies. At the same time, physicians are identifying an increased number of patients with treatment-related cardiotoxicity. It is imperative that physicians recognize early treatment-related adverse effects to determine the safest therapeutic options for patients with cancer. This manuscript evaluates the role of cardiovascular imaging and biomarkers in identifying cardiotoxicity trigged by various chemotherapeutic agents and summarizes expert consensus statements regarding cardiotoxicity monitoring.

Neuroendocrine neoplasms arise from the gastrointestinal tract and can lead to carcinoid syndrome. Carcinoid heart disease affects more than half of these patients and is the initial presentation of carcinoid syndrome in up to 20 % of patients. Carcinoid heart disease typically leads to valve dysfunction, but in rare instances, carcinoid tumours can also metastasise to the endocardium and myocardium. Cardiovascular imaging plays an integral role in the diagnosis and prognosis of carcinoid heart disease. The use of multimodality imaging techniques including echocardiography, cardiac MRI, cardiovascular CT and positron emission tomography have allowed for a more comprehensive assessment of carcinoid heart disease. In this review, we discuss the features of carcinoid heart disease observed on multimodality imaging, indications for obtaining imaging studies and their role in carcinoid heart disease management.

Cancer patients with CAD & thrombocytopenia are usually managed non-invasively due to perceived high risk of procedural complications (i.e. bleeding). Initial experience suggested feasibility of coronary angiography (CA) irrespective of platelet count. We sought to determine if thromboelastogram (

Background The systemic inflammatory and hypercoagulable states, as well as the cardiotoxic effects of chemo-radiation therapies, expose cancer patients to a wide spectrum of cardiovascular comorbidities that may require cardiac catheterization. The presence of thrombocytopenia increases the risk for significant bleeding during endovascular procedures. We sought to evaluate the clinical characteristics and outcomes of cancer patients with chronic thrombocytopenia undergoing cardiac catheterization for evaluation of cardiomyopathy. Methods We performed a retrospective study of patients with preprocedural thrombocytopenia undergoing cardiac catheterization indicated for cardiomyopathy (chemotherapy-induced, myopericarditis, Takotsubo, or other cardiomyopathies) between November 2009 and November 2015 at our institution. Preprocedural platelet counts were classified into 3 groups: mild thrombocytopenia (>50 K/µL), moderate thrombocytopenia (30-50 K/µL), and severe thrombocytopenia ( Results Out of a total of 148 patients that underwent coronary angiography, 50 (33.8%) had cardiomyopathy as the indication (Table). Mean platelet count on admission was 44.1 ± 29.2 K/µL. Severe thrombocytopenia was identified in 22 patients (44%), moderate thrombocytopenia in 7 patients (14%), and mild thrombocytopenia in 21 patients (42%). No periprocedural bleeding or major adverse cardiovascular events were noted. Median overall survival (OS) was 6.9 months. Patients who had congestive heart failure had significantly decreased OS (p = 0.01). Decreased hemoglobin (p = 0.08), moderate thrombocytopenia (p = 0.03), severe thrombocytopenia (p = 0.09), and LVEF Conclusions Thrombocytopenia should not represent an absolute contraindication for cardiac catheterization in cancer patients with cardiomyopathy and can be considered when hemodynamic data or information obtained invasively may impact clinical care.